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Complications of labor
- 1. Complications of Labour IqraYasin Resident, Obs/Gyne Unit I SIMS/Services Hospital, Lahore
- 2. Uterine Inversion ā¢ Incidence: ā¢Varies according to geographical locations; ranges from 1:2500 to 1:20000 ā¢ Definition: ā¢ Turning of the uterus of its inside out, so that fundus prolapse through the cervix
- 3. Uterine Inversion CLASSIFICATION According toseverity of uterine inversion According to timing of the event Incomplete uterine inversion First degree Fundus reaches the internal os Acute Occurs within 24 hours of birth Second degree Body or corpus of the uterus is inverted to the internal os Subacute Occurs after 24 hours, within 4 weeks Complete uterine inversion Third degree Uterus, cervix and vagina are inverted and are visible chronic Occurs after 4 weeks, rare.
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- 5. Uterine Inversion ā¢ Causesand Risk factors: ā¢ Use of fundal pressure when uterine is atony during placental delivery ā¢ Premature or excessive cord traction during active management of 3rd stage of labor ā¢ Others: ā¢ Fundal attachment of placenta ā¢ Abnormally adherent placenta ā¢ Short umbilical cord ā¢ Manual removal of placenta ā¢ Primary parity ā¢ Microsomic baby ā¢ Unicornuate or bicornuate uterus ā¢ Cervical lacerations ā¢ Antepartum use of magnesium sulphate
- 6. Uterine Inversion ā¢ Signsand Symptoms ā¢ Severe lower abdominal pain ā¢ Feeling of prolapse ā¢ Shock (hemorrhagic, neurogenic) ā¢ Abdominally impalpable(complete) fundus, with plump colored mass felt in vagina if placenta is separated. ā¢ Versus dimpled(incomplete) fundus
- 7. Uterine Inversion MANAGEMENT ā¢ CALLFOR HELP ! ( Senior Obstetrican/staff/anesthestic) ā¢ Maternal resuscitation while attempting uterine replacement should be initiated simultaneously. ā¢ If the placenta is still in situ, leave in place until uterine replacement is complete. ā¢ Attempt manual replacement of the uterus by re-inverting it and keeping the hand in the uterus until firm contraction of the uterus is felt.
- 8. Uterine Inversion ā¢ Managementof Shock: ā¢ Insert two 16 gauge intravenous cannula. ā¢ Group and cross-match 4 units of blood and order a full blood picture ā¢ Consider performing coagulation studies. ā¢ Commence intravenous fluids: ā¢ If the woman has blood loss more than 1000mls, continues to bleed, or show signs of clinical shock7, in consultation with the anesthetist the volume and rate of fluids is adjusted according to the clinical situation. ā¢ Warming of the solution may be required.
- 9. Uterine Inversion ā¢ Managementof Shock: ā¢ If not already administered, withhold the oxytocic until uterine replacement is complete. ā¢ Assess vital signs - blood pressure, pulse, respirations, and oxygen saturation levels 15 minutely (more frequently if maternal conditions necessitates). ā¢ Monitor vital signs continuously as soon as practical with access to continuous monitoring equipment. ā¢ Administer oxygen via a face mask.
- 10. Uterine Inversion ā¢ Managementof Shock: ā¢ Insert an indwelling catheter. Monitor urine output. ā¢ If the uterus is successfully replaced commence an oxytocic infusion (30iu SyntocinonĀ® in 500mL Hartmannās solution commencing at 240mL / hour) as per PPH therapeutic infusion regimen. ā¢ If the replacement of the uterus is not possible, resuscitate the woman and transfer her to theatre immediately.
- 11. Uterine Inversion MANUAL REPLACEMENT(JOHNSON MANOEUVRE). The uterus may require relaxation prior to manual replacement. 1. Using the palm of the hand push the fundus of the uterus along the direction of the vagina towards the posterior fornix. 2. Then lift the uterus towards the umbilicus and return to its normal position. 3. Maintain the hand in situ until a firm contraction is palpated. Oxytocin therapy should be administered to initiate and maintain contraction of the uterus.
- 12. Uterine Inversion MANUAL REPLACEMENT(JOHNSON MANOEUVRE).
- 13. Uterine Inversion HYDROSTATIC REDUCTION(OāSULLIVANāS TECHNIQUE) ā¢ Warm saline is administered into the vagina through a nozzle from a can held one meter above the patient. ā¢ Leakage from vagina is prevented by holding the labia together. ā¢ Pressure built by fluid pushes the uterine fundus gradually to its normal site.
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- 16. Perineal tear ā¢ Definition: ā¢Spontaneous laceration of skin and/or soft tissue in woman which separates vagina from anus. ā¢ Incidence: ā¢ UK (overall 2.9 %, 6.1 % in primiparae versus 1.7 % in multiparae)
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- 18. Perineal tear ā¢ Causesand predisposing factors
- 19. Perineal tear ā¢ Allwomen having vaginal delivery at risk of obstetric anal sphincter injuries and should be examined ā¢ All women have DRE after the repair
- 20. Perineal tear ā¢ Complicationsof repair ā¢ Hemorrhage ā¢ Hematoma ā¢ Fistula due to deep suturing involving rectal mucosa ā¢ Dyspareunia ā¢ Misaligned repair ļ increased scarring and distrotion of area
- 21. Perineal tear ā¢ Postrepair care: ā¢ Analgesia ā¢ Antibiotics ā¢ Laxatives ā¢ Sitz bath ā¢ Physiotherapy ā¢ Pelvic floor exercises ā¢ Keep clean dry and change sanitary pads ā¢ Cotton underwear
- 22. Perineal tear ā¢ Followup after 6-12 weeks ā¢ Prognosis ā¢ 60-80 % ā¢ Asymptomatic after 12 months of repair
- 23. Perineal tear Prevention: Several techniquesare used to reduce the risk of tearing, but with little evidence for efficacy. 1. Antenatal digital perineal massage is often advocated, and may reduce the risk of trauma only in nulliparous women. 2. āHands onā techniques employed by midwives, in which the foetal head is guided through the vagina at a controlled rate have been widely advocated, but their efficacy is unclear. 3. Waterbirth and labouring in water are popular for several reasons, and it has been suggested that by softening the perineum they might reduce the rate of tearing. However, this effect has never been clearly demonstrated.
- 24. Perineal tear ā¢ RiskManagement
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- 41. Puerperal genital hematomas ā¢Investigations ā¢ Blood : CBC, Coagulation profile, blood group/matching ā¢ US, CT, MRI
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- 48. Cervical tear/laceration ā¢ CAUSES ā¢Rigidity of cervix ā¢ Abnormal structure due to scarring from previous surgery ā¢ Rapid delivery of head in breech presentation ā¢ Lack of antenatal care ā¢ Unsupervised delivery ā¢ Delivery by inexperienced/untrained health worker ā¢ Manual dilation of cervix ā¢ Improper selection of patient for instrumental delivery ā¢ Application of vacuum/forceps before cervical dilation
- 49. Cervical tear/laceration ā¢ Importantto identify apex of cervical tear ā¢ Deep blind sutures at fornix ļ leads to damage of ureter ā¢ Failure of identification of apexļ leads to suspicion of broad ligament hematoma ā¢ In severe bilateral tear ļ extend to broad ligament ļ leading to rupture of uterine vessels ā¢ Anterior tear ļ can extend into bladder ā¢ Suspected when continuous bleeding in absence of contracted uterus and perineal trauma
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